Asthma Management - Science topic

No, antihistamines do not improve bronhial asthma. Some benefits could be present in rhinitis, asociated to asthma.

That was really really helpful

I appreciate that

You can designed a new developed tools

Dear Ramachandra, 

Thank you for this interesting question. 

As you describe, asthma management is a combination of these two factors, but it´s important to have in mind that the therapeutic options in both approaches are varied. But also, not only these medications are considered useful for the asthma management. Environmental control and health promotion programs for asthma are fundamental aspects of the control of this disease. 

You can get more resources about this approach in the GINA Website.

Best, 

Juan Yepes

pediatrics asthma guidelines are to some extent similar to adults.you can use the following guideline too.

Well despite the Guidelines which we often forget are just that and do not equally apply to all patients--I prefer an individualized approach.

I am assuming This is a child old enough to do pulmonary function tests--if so the results can guide you,  The paient is having syptoms--yes? If the Pulmonary Function Test is fairly normal(=/> 80%) then this tell me that they do not need a LABA but more ICS .  One reason they may need more they are not taking correctly what they have been given---not inhaling correctly --and/or using less frequent doses than recommended.  Before increasing the dose check what they are doing---and remember patients do not always tell you the entire truth.

Even before adding a LABA, if the Mid Flow Rates (FEF 25-75%) are low consider the small airways may not be getting the ICS because some ICS have too large of a particle size to reach the small airway--So switch brands or delivery system. ( Dry Power Inhalers have the largest particle size so switching to a MDI/HFA system may be enough.

If one needs to increase the dose of ICS --I would never go above the recommended dose without careful adverse effect monitoring (Growth) and ruling out (??even again) that there is NOT something other than or in addition to Asthma going on.

Finally remeber that not all Asthma Patients respond to ICS equally---see the new GINA Guidelines on Heterogenity.

Good Luck

Response to ICS may show variability over time in some asthma patients, but development of total resistance to ICS in a patient previously considred as good responder should be considered an exceptional case.

Short term reduction in the response ot ICS can be seen in asthma patients suffering viral infections.Recent studies have shown that viral infections can reduce the antiinflammatory effects of glucocorticoids (GC) by altering the GC receptor function (see Elena Goleva sudies). Exposure to potent allergens at home (cats ,hamster, etc) or to occupational allergens or irritative substances may also explain an apparent reduction in the response to ICS.

As Dr Kodgule pointes out a limited efficacy of ICS to prevent progressive decline in lung function test is frequently detected in the follow-up of asthma patients. This observation suggests that ICS are very useful to prevent asthma exacerbations, reduce mortality and increase the quality of life of patients, but are less efective to prevent remodelling and therefore progression in airway obstruction.

Finally, when a patient develops refractoriness to ICS, poor compliance is the most frequent explanation in clinical practice.

Reversible airflow obstruction in Bronchial Asthma is defined as increase in FEV1 by > 200 ml & FEV1 > 12% post bronchodilator challenge . COPD is defined as post bronchodilator FEV1 / FVC < 0.7 which confirms that airflow obstruction is not fully reversible . If there is no post bronchodilator reversibility in bronchial asthma , it should be considered as fixed air flow obstruction . The main problem is that if spirometric findings of Bronchial Asthma is suggestive of COPD in elderly patients , it is difficult to diagnose the Asthma component ,unless the history of childhood wheeze , allergy , dry cough & non smoking is available

discontinuation of the ICS in patients showing controlled asthma for e.g. 3 months is the option indicated in the guidelines leading to the minimum possible therapy (fast-acrting bronchodilator alone as needed) btu the evidence is D. However, there is increasing evidence supporting the intermittent as needed use of fixed combinations of ICS and rapid-acting bronchodilators (e.g. salbutamol or formoterol) which has several advantages over the single bronchodilaotr monotherapy. first of all asthma is an inflammatory disease and even if symptoms are infrequernt and lung function is normal, inflammation has to be addressed. Leaving a patient with rescue bronchodialtor only as antiasthmatic therapy is nowadays, not the best option in my opinion.

rescue use of fawst-acting bronchodilartor/ICS combination allows the patient to have a symptom-drtiven treatment and adjust the need in case of symptoms increase. The ICS in the combination can have a rapid effect on the flares of inflammation leading to symptoms increase and can contribute avoiding the acute worsening of the disease.

Moreover, a patient with as needed bronchiodilator alone therapy would need to be mnonitored frequently to check if the use is more than twice a week in order to consider a step-up in therapy.

to make a long story short I do not think stopping ICS is a good option.

A useful reading: Rescue treatment in asthma. More than as-needed bronchodilation. Papi A, Caramori G, Adcock IM, Barnes PJ.

Chest. 2009 Jun;135(6):1628-33.

" Our update in 2012 is consistent with the original conclusions that the risk-benefit balance of intravenous aminophylline is unfavorable." (Ref: Parameswaran Nair,, Stephen J Milan, Brian H Rowe ,.Addition of intravenous aminophylline to inhaled beta2-agonists in adults with acute asthma, Editorial Group: Cochrane Airways Group, DOI: 10.1002/14651858.CD002742.pub2 )

IV Magnesium sulphate is an alternative if other treatments like beta agonists and steroids do not produce good response.

(Ref: W. F. S. Sellers, Inhaled and intravenous treatment in acute severe and life-threatening asthma, Br. J. Anaesth. (2012) doi: 10.1093/bja/aes444 )

ictorial based asthma self management plans may be used as an additional tool during a consultation to improve compliance and understanding or to provide self-management education. Other tools and information during consultations can improve compliance and understanding, such as provision of leaflets, pictorial aids and diagrams and providing further information links and leaflets post consultation. It has been shown that these consultation tools improve understanding for all patients as well as those with low literacy skills.